Radiation therapy knowledge exchange

ABSTRACT

A method for implementing a radiation therapy knowledge exchange starts with searching a database of cases studies and selecting a case study. The selected case study is downloaded. The downloaded case study is applied to a medical case, wherein the downloaded case is applied using deformable image registration to deform reference images of the downloaded case to medical images of the medical case. After application of the downloaded case study, the medical case is uploaded to the network, wherein uploading the medical case allows at least the submitting clinician to download, review, and edit at least a portion of the medical case to create a reviewed medical case. Finally, the reviewed medical case is downloaded and applied to the medical case to create a final medical case.

TECHNICAL FIELD

The present disclosure relates generally to the field of RadiationTherapy and more specifically a collaborative exchange of knowledge forimproving best practices in Radiation Therapy.

BACKGROUND

Oncology and Radiotherapy technology continues to evolve, acceleratingthe expansion of the envelope of possible treatments and best practicesassociated with those possible treatments. At the same time, thecomplexity of clinical decisions is increasing non-linearly, resultingin a rapidly widening gap between actual practice and best practices,especially in emerging markets.

For example, when medical imaging is necessary in the course ofradiation therapy, several systems may be used, such as X-ray, magneticresonance imaging (MRI), computed tomography (CT), and others. When CTor MRI imagery, for example, is used, a series of two-dimensional imagesare taken from a three-dimensional volume. Here, each two-dimensionalimage is an image of a cross-sectional “slice” of the three-dimensionalvolume. The resulting collection of two-dimensional cross-sectionalslices can be combined to create a three dimensional image orreconstruction of the patient's anatomy. This resultingthree-dimensional image or three-dimensional reconstruction will containorgans of interest. Those organs of interest include the organ targetedfor radiation therapy, as well as other organs that may be at risk ofradiation therapy exposure. The portion of the three-dimensional imageor reconstruction that contains the organs of interest may be referredto as structures of interest or volumes of interest.

These one or more structures of interest may be viewed in several ways.A first and simplest way to view the structure(s) of interest would beto merely view the original CT or MRI image slices for the patient, witheach slice containing a view of the structure(s) of interest. A second,and more complicated method to view the structure(s) of interest wouldbe to combine the series of two-dimensional cross-sectional slices intoa single three-dimensional representation where the structure(s) ofinterest may be represented as solid, opaque, or translucent, etc.,objects that may then be manipulated (e.g., rotated) to allow viewingfrom multiple angles.

One purpose of the three-dimensional reconstruction of the structure(s)of interest containing diseased or abnormal tissues or organs is thepreparation of a three-dimensional radiation therapy treatment plan.Radiation therapy treatment plans are used during medical proceduresthat selectively expose precise areas of the body, such as canceroustumors, to specific doses of radiation to destroy the undesirabletissues. To develop a patient-specific radiation therapy treatment plan,information is extracted from the three-dimensional model to determineperimeters such as organ shape, organ volume, tumor shape, tumorlocation in the organ, and the position or orientation of several otherstructures of interest as they relate to the affected organ and anytumor.

The two-dimensional slices may be individually viewed on a computerscreen and with the use of conventional graphics programs, the contoursof organs or structures of interest can be traced out by hand. Contoursare connected line segments that define the outline of a structure ofinterest, which may be an organ, a portion of an organ, a tumor,diseased tissue, or a whole patient outline. Alternatively, thesestructures of interest in specific organs such as the brain or prostate,for example, may be identified with various structure-specific automaticcontouring and/or automatic segmentation software programs (subdividingan image into discrete regions) that outline or fill the shape of thestructure of interest on each two-dimensional slice of a set of slices.

As evolving technologies provide increasingly complicated radiationtherapy treatment planning possibilities, the gap between actualclinical practice and possible best practices increases. Thereforeimproved methods for realizing and communicating improved results usingemerging technological innovations are required.

SUMMARY OF THE INVENTION

This present invention provides a solution to the challenges inherent inachieving radiation therapy best practices. In a method according to oneembodiment, a series of steps provide a knowledge-based radiationtherapy exchange. The method starts by searching a database of casesstudies and selecting a selected case study. The selected case study isdownloaded into a tool set. The downloaded case study is applied to amedical case in the tool set, wherein the downloaded case is appliedusing deformable image registration to deform reference images of thedownloaded case to medical images of the medical case. After applicationof the downloaded case study, the medical case is uploaded to theexchange, wherein uploading the medical case allows at least a clinicianwho contributed the selected case study to download, review, and edit atleast a portion of the medical case to create a reviewed medical case.Finally, the reviewed medical case is downloaded and applied to themedical case to create a final medical case.

BRIEF DESCRIPTION OF THE DRAWINGS

The present invention will be better understood from a reading of thefollowing detailed description, taken in conjunction with theaccompanying drawing figures in which like reference charactersdesignate like elements and in which:

FIG. 1 is a simplified block diagram illustrating an embodiment of aknowledge-based radiation treatment exchange, in accordance with anembodiment of the present invention;

FIG. 2 is a simplified block diagram illustrating reference image setsand a medical image set, in accordance with an embodiment of the presentinvention;

FIG. 3 is a simplified block diagram illustrating an embodiment of aknowledge-based radiation treatment exchange, in accordance with anembodiment of the present invention

FIG. 4 illustrates steps of example processes for implementing aradiation therapy knowledge exchange, in accordance with an embodimentof the present invention; and

FIGS. 5A-5C illustrate steps of an example process for implementing aradiation therapy knowledge exchange, in accordance with an embodimentof the present invention.

DETAILED DESCRIPTION

Reference will now be made in detail to the preferred embodiments of thepresent invention, examples of which are illustrated in the accompanyingdrawings. While the invention will be described in conjunction with thepreferred embodiments, it will be understood that they are not intendedto limit the invention to these embodiments. On the contrary, theinvention is intended to cover alternatives, modifications andequivalents, which may be included within the spirit and scope of theinvention as defined by the appended claims. Furthermore, in thefollowing detailed description of embodiments of the present invention,numerous specific details are set forth in order to provide a thoroughunderstanding of the present invention. However, it will be recognizedby one of ordinary skill in the art that the present invention may bepracticed without these specific details. In other instances, well-knownmethods, procedures, components, and circuits have not been described indetail so as not to unnecessarily obscure aspects of the embodiments ofthe present invention.

Notation and Nomenclature:

Some portions of the detailed descriptions, which follow, are presentedin terms of procedures, steps, logic blocks, processing, and othersymbolic representations of operations on data bits within a computermemory. These descriptions and representations are the means used bythose skilled in the data processing arts to most effectively convey thesubstance of their work to others skilled in the art. A procedure,computer executed step, logic block, process, etc., is here, andgenerally, conceived to be a self-consistent sequence of steps orinstructions leading to a desired result. The steps are those requiringphysical manipulations of physical quantities. Usually, though notnecessarily, these quantities take the form of electrical or magneticsignals capable of being stored, transferred, combined, compared, andotherwise manipulated in a computer system. It has proven convenient attimes, principally for reasons of common usage, to refer to thesesignals as bits, values, elements, symbols, characters, terms, numbers,or the like.

It should be borne in mind, however, that all of these and similar termsare to be associated with the appropriate physical quantities and aremerely convenient labels applied to these quantities. Unlessspecifically stated otherwise as apparent from the followingdiscussions, it is appreciated that throughout the present invention,discussions utilizing terms such as “ processing” or “accessing” or “executing” or “ storing” or “rendering” or the like, refer to the actionand processes of a computer system, or similar electronic computingdevice, that manipulates and transforms data represented as physical(electronic) quantities within the computer system's registers andmemories and other computer readable media into other data similarlyrepresented as physical quantities within the computer system memoriesor registers or other such information storage, transmission or displaydevices. When a component appears in several embodiments, the use of thesame reference numeral signifies that the component is the samecomponent as illustrated in the original embodiment.

This present invention provides a solution to the increasing challengesinherent in improving and communicating radiation therapy bestpractices. In particular, various embodiments of the present disclosureprovide a knowledge exchange allowing clinical consumers and clinicalproviders to share best practices in Radiation Therapy treatmentincluding radiation therapy prescriptions, delineation of organs, tumorsand regions within medical images for treatment planning (e.g., contoursand segmentation of organs of interest), radiation therapy treatmentplanning, and radiation therapy treatment protocols, to name a few.

By creating an open knowledge exchange, users of the knowledge exchangewill be able to generate and share valuable clinical content. Further,these users of the knowledge exchange will be able to collaborate tosolve their own problems and share solutions with others. Further, theknowledge exchange will help accelerate the adoption of newtechnological developments by enabling the rapid development of clinicalcase examples using the new technological developments that demonstratenot only “what” to do, but also “how” and “why.”

The advancement of sophisticated electronic tools employed in the fieldof radiation therapy allows this exchange to be in the form of editableelectronic clinical files related to each of the treatment steps.Combining these electronic clinical files together around a specificclinical case enables a new method of sharing of case specific clinicalbest practice. Electronic clinical case files are assigned meta-datatags that allow the case files to be searched using a search engine.Such searching will allow a particular expert case to be identified byat least one identifying characteristic, such as weight, height, sex,age, race, size of patient, diagnosis, treatment site, whether or notthere is nodal involvement, any co-morbidities, side of the body, andapproximate location of tumor, etc. The electronic files includeclinical process descriptions, or protocols, that can be combined withoutcomes information to create significantly stronger statistical linksbetween radiation therapy protocols and resulting outcomes. Inparticular, a clinician wishing to download an “expert” case study withsimilar meta-data as their patient will receive a reference image setcontaining the delineation of organs, tumors and regions within images(e.g., contours and segmentation of organs of interest) for treatmentplanning that may be applied to their own patient as described below.

Combined with widely available collaborative networking tools, theadoption of standard interfaces allowing electronic capture and transferof clinical knowledge, and the existing paradigm of sharing content viaan electronic market, a hub may be created for the creation anddissemination of Oncology knowledge. The electronic content willrepresent a form of intellectual property, or copywrite, held by anauthoring clinician, which can be either sold or given to others onthese networks.

An exemplary embodiment of the radiation therapy knowledge exchangeplatform will allow an author/clinician to post case files (herein alsoreferred to as case studies) and then host a collaborative webdiscussion with those who download the case files about the methodologydescribed in the case files. Sharing and discussing the electronicinformation can occur in either configurable public or private networks.In other words, the posted case files may be placed into a privatenetwork that only selected other clinicians/reviewers will have accessto review and comment on, or the posted case files may be placed into apublic network that any clinician/reviewer that is part of the knowledgeexchange has access to review and comment on.

In an exemplary embodiment, other clinicians who download the casestudies may review and rate the quality of the individual case studies,creating a new type of peer review process for clinical data. A group ofclinicians may chose to elect a particular clinical case forcollaborative refinement and promote its status to that of an “expertcase,” which indicates a high-level of peer review and acknowledgementof excellence from the community.

This new method of sharing and developing new best practices willsupplement and enhance the existing practice of publishing papers. Thebenefits include direct and more explicit transfer of clinical bestpractice in the form of electronic templates, a platform forsignificantly quicker clinician to clinician discussion around how touse these techniques, and more detailed clinical process informationallowing a stronger statistical link to clinical outcomes data.

In an exemplary embodiment, the knowledge exchange will consist of a website where participants (e.g., contributing clinicians and consumerclinicians downloading case studies) can both post and download content.Access to the web site will require user identification and signingusage agreements. The web site will include a search engine that willsearch the knowledge-base according to meta-data categories such as:weight, height, sex, age, race, size of patient, diagnosis, treatmentsite, whether or not there is nodal involvement, any co-morbidities,side of the body, and approximate location of tumor, etc. Indication ofthe practitioner's particular clinic tool set is necessary becausedifferent clinical tool sets have different requirements that must bedistinguished. For example, a RapidArc® plan assumes you have theRapidArc tools to execute it.

Knowledge Organization

The electronic clinical content will be organized around individualclinical case studies and provide an important reference and startingpoint for the specific patient case across the clinical process. Inaddition to providing contour information, the electronic content of thecase study will include one or more examples of treatment plans for thesame case, with the relevant care path and prescription. In oneembodiment, a clinic tool set will be able to import and export to otherclinic tool sets. In addition to specific content to be loaded intoproducts, the knowledge exchange will provide access to relatedinformation including papers, posts, videos, and blogs on the sametopic. In one embodiment a case study will contain a reference image setwith associated contouring and segmentation of organs or structures ofinterest, treatment plan parameters, an achieved plan, follow-on carepath for the patient represented in the case study, and what thelong-term outcome for the case study patient was. In other words, thecase study will have captured and presented the whole patient history.Further, each individual component of the case study (image set,contouring, segmentation, treatment plan parameters, etc.) hasindividual value and potential consumer clinicians may wish toborrow/purchase only individual pieces of the case study and apply it totheir current patient, or borrow/purchase the entire case study andapply the entire case study to their patient as a complete methodologyof treatment.

The tool sets are able to directly read the parametric information ofthese downloaded case studies. With the ability to transfer informationthat has clinical value, that's parametric to patients, and with theability to socially network, putting that together around reference casestudies and current medical cases in need of solutions, there is now anew way of communicating clinical best practices. The consumer cliniciancan download a case study, register a reference image set to a medicalimage set for the current patient and bring in parametric data from thedownloaded case study into the treatment plan and make any necessaryadjustments, as discussed below. The consumer clinician therefore has avaluable starting point. For example, the case study comprises theparameters used in the case study, descriptors describing the rationalebehind the parameters, and a case description of the case study, therebyproviding the consumer clinician with the full context of the case study(in other words, lecture, theory, practice, a full suite of parameters,and instructions to accomplish a complete radiotherapy treatmentplanning session).

FIG. 1 illustrates an embodiment of a knowledge exchange 100. Theknowledge exchange 100 in FIG. 1 comprises a knowledge exchangeinterface 102 that includes a database 104 comprising a plurality ofindividual case studies 106 a-106 n. FIG. 1 illustrates that varioustypes of users will be connected to the knowledge exchange interface102. These users include consumers 108, contributor/reviewers 110,contributor/consumers 112, and contributor/reviewer/consumers 114. Aconsumer 108 is defined as a clinician who wishes to download and use acase study as a reference and starting point for a specific case acrossthe clinical process. A contributor/reviewer 110 is defined as aclinician who wishes to upload case studies for others to download anduse or review, as well as one who wishes to download case studies toreview them. Such reviewers 110 may be taking part in the peer reviewprocess for submitted case studies 106, as well as reviewing the resultsachieved when a consumer clinician 108 has downloaded and used one ofthe contributor/reviewer's 110 submitted case studies 106 and is nowseeking feedback. In one embodiment it is anticipated that after aconsumer downloads a selected case study from a particular contributorand applies the case study to their specific patient case, thecontributor will be able to review the consumer's results and provideadvice and feedback as to the achieved results. In another embodiment itis also anticipated that the consumer will be able to seek advice,review, and feedback from the contributor as well as other reviewers whomay be interested in providing the desired review and feedback. Acontributor/consumer 112 is defined as a clinician who wishes to uploadcase studies to the knowledge exchange for peer review and use byothers, as well one who wishes to download and use a case study as areference and starting point for a specific case across the clinicalprocess. Finally, a contributor/reviewer/consumer 114 is defined as aclinician who wishes to contribute case studies to the knowledgeexchange for peer review and use by others, to review case studies ofothers as part of the peer review process as well as reviewing theresults of those who've downloaded their submitted case studies to use,and finally as one who also wishes to download and use a case study as areference point starting point for a specific case across the clinicprocess. All knowledge exchange participants mentioned above downloadand/or upload content to or from the knowledge exchange, such that allreviewing, editing, and applying of case studies to specific patientcases takes place within tool sets off line.

Contributing to the Knowledge Exchange

In an exemplary embodiment, a clinician who plans to publish a paper onthe use of a particular tool set for head-and-neck cases could log ontothe knowledge exchange website and upload the clinical case studyinformation, including contours, treatment plan, care plan, andprescription. The submitted clinical case study or studies would be theintellectual property of the clinician who posted the case study;therefore, the contributor dictates the IP status and price to download(if any). This posting can also include related papers, images, videos,and comments.

In one embodiment, when a contributing clinician posts a case study tothe knowledge exchange, the contributing clinician may host a chat roomto support questions and discussion around that particular case study.Further, clinicians who either review or download the case study (e.g.,to use the case study) will be able to post in the chat room to discussthe reviewed or downloaded case study.

Rating and Quality Control

In one embodiment, users of the knowledge exchange will be able to ratethe quality of submitted case studies using for example, a 5-star ratingsystem. Further, these reviewers will also be able to write a review ofthe clinical content of the reviewed case study. The ratings associatedwith each clinical case study belonging to a contributor will also beaggregated to create an overall reputation rating for the contributingclinician. The scoring system can be used as incentive for individualsin the knowledge exchange community, and can be used by an embodiment ofthe system to recognize prolific and high-quality contributors.

Initially, an embodiment will establish a clinical advisory board topreview all case studies before allowing them to be published; however,once the knowledge exchange is fully established, it is expected thatthe community will be able to self-police effectively. In anotherembodiment, the clinical advisory board will be maintained to recognizeand certify popular and highly rated contributions. In discussionforums, blogs, and case study reviews, positive and negative posts aboutthe knowledge exchange and other user-interactive networks, will bepermitted, although the Knowledge Exchange will be monitored andoffensive or irrelevant items will be removed as needed. In cases ofextreme abuse, blatant misrepresentation, or by request of crediblemembers of the community, specific contributors may be banished from thecommunity.

Such ratings for individual case studies as well as ratings forcontributing clinicians with the addition of “expert” case studies andthe recognition of particular contributing clinicians with expertise inparticular areas will be immediately useful to potential consumerclinicians. For example, some contributing clinicians will be experts intreating a particular form of disease and their expertise will be highlyvalued and sought after by others. In other words, the rating systemallows consumer clinicians to know who the expert contributingclinicians are as well as knowing what are considered by the knowledgeexchange community (as well as by the clinical advisory board) to beexpert case studies. This allows a consumer clinician to provide atreatment plan methodology of a distant team of experts for his ownpatient. As noted above, the treatment plan methodology may contain allor part of the electronic contents of the case study.

Each contributing clinician will have a rating and each contributed casestudy will have its own peer rating. Therefore, when a consumerclinician searches the database of case studies in the knowledgeexchange they may request case studies submitted from clinicians with atleast a minimum aggregate rating score (which may also be referred to asa reputation score, based upon an aggregate of the ratings of theirsubmitted case studies) and case studies with a minimum peer reviewrating.

In one embodiment, to promote the contribution of case studies and thereviewing of submitted case studies (from contributing clinicians) andapplied case studies (from consumer clinicians), contributing andreviewing clinicians may receive a kind of “currency” for each casestudy they submit or review. Such a currency may in embodiments of theknowledge exchange be spent, for example, by purchasing case studies todownload and use at a discount.

A Consumer Wishing to use the Knowledge Exchange

An exemplary consumer clinician interested in head-and-neck treatmentswould follow an exemplary process comprising the following steps:

-   -   1. Log onto the knowledge exchange website where they would        enter the type of case, diagnosis and stage, and tool set        treatment technique into the search engine. As discussed in        detail below, there are other search criteria also available. If        this was the first time they had logged onto the knowledge        exchange, they would also need to setup a user name/password, as        well as setup a new user account.    -   2. The search engine will return several cases posted by other        contributing clinicians as well as related posts, videos, and        blogs on the same topic.    -   3. The consumer clinician can browse the profiles of various        contributors, read the reviews of various case studies, and        chose one that best meets their needs.    -   4. The consumer clinician in one embodiment makes an electronic        payment to the poster (the host providing the service will take        a nominal commission) and downloads the case study. A fee (if        any) for downloading the case study will be set by the        contributing clinician.    -   5. The case study will be formatted for the particular clinical        tool set the consumer clinician utilizes and automatically        loaded into the target tool set.    -   6. Once downloaded, the consumer clinician is able to modify the        case study for their clinic and apply it to an individual        patient. The clinician can read any attached papers and watch        any videos or other presentations. Additionally, they may post        questions about the case for the clinical community to help        answer. It is anticipated that as discussed above and below, one        member of the clinical community that will be available to        provide review and feedback will be the clinician who        contributed the downloaded case study to the knowledge exchange.

The consumer clinician after downloading the desired case study will beable to load the case study into their own tool set and have an exampleto show them what the final result in the case study looked like, aswell as how it looks in their own medical image set (deformable imageregistration used to deform the reference images to the medical image,as discussed in detail below). Therefore, the consumer clinician cancompare their prepared treatment plan to the treatment plan in thedownloaded case study. This allows the consumer clinician to look at thefinal result of the case study and compare it to their own results andthen make any adjustments to their own treatment plan based upon thedownloaded case study. In other words, the knowledge exchange allows theconsumer clinician to compare their own results relative to somestandard, which can be especially useful when it is a particular medicalcondition that the consumer clinician has limited experience with.

The Knowledge Exchange Interfacing with a Tool Set:

FIGS. 2 and 3 illustrate an embodiment of the knowledge exchangeinterfacing with an exemplary tool set. The contents of an electroniccase study, as discussed above, comprise a metadata file, pdfs, othertext documents, audio/video files and an executable to run on theparticular tool set. The tool sets are able to directly read theparametric information of these downloaded case studies. Such a tool setprovides for example automatic contouring and automatic segmentation ofeach of the two-dimensional cross-sectional slices used in forming athree dimensional image according to the rule set provided in the casestudy, such that the reference image set may be applied to the medicalimage set. Such an image set is discussed by Zankowski, in pending U.S.patent application Ser. No. 12/845,358, filed Jul. 28, 2010, entitled“KNOWLEDGE-BASED AUTOMATIC IMAGE SEGMENTATION,” which is incorporatedherein by reference. As illustrated in FIG. 2 and discussed by Zankowskiin the above patent application, each downloaded case study 106comprises a reference image set 202 with a plurality of two-dimensionalslices. A reference image set 202 also comprises meta-data, a sparselandmark signature corresponding to the reference image, and a pluralityof segments and contours corresponding to structures of interest 204a-204 n seen in each individual reference image slice. As furtherdiscussed by Zankowski, the particular patient case in the particulartool set includes a medical image set 206 with a plurality oftwo-dimensional slices. The medical image set 206 also includes aplurality of structures of interest 204 a-204 n seen in the individualtwo-dimensional slices of the medical image set 206, but withoutcontouring and segmentation.

The tool set processes the medical image set 206 to reduce each slice ofthe medical image set 206 to a sparse landmark signature. In anembodiment of the present invention, and as discussed by Zankowski, thesparse landmark signature set made of all the sparse landmark signaturesof the individual slices are also used in the selection process to finda suitable reference image set. Such use of the sparse landmarksignature set may also be used to select a suitable case study. After aparticular case study 106 has been selected and downloaded by theconsumer clinician, the reference image set 202 of the selected casestudy 106 is deformed to the medical image set 206 in the tool set. Inother words, the points in the sparse landmark signature of thereference image set 202 (one slice at a time) is deformed to the pointsin the sparse landmark signature set 304 of the medical image set 206.

In one exemplary embodiment, a deformable image registration algorithmwill take the selected reference image set 202 and the medical image set206, which has no segmentation or contouring and morph the referenceimage set 202, one slice at a time, to look like the medical image set206. The registration algorithm will also transfer the contours from thereference image set 202 to the medical image set 206 as well. Therefore,each of the points from the reference image set 202 are deformed to thepoints of the medical image set 206. After the consumer clinicianreviews and makes any manual adjustments to the results as seen in thenow contoured and segmented medical image set 206, the consumerclinician is able to upload the results to the knowledge exchange toseek feedback on how well the contours and segmentations fit the organsor structures of interest 204 a-204 n in the medical image set 206.

FIG. 3 illustrates an embodiment of the knowledge exchange 100interfaced with a particular tool set 302. In one embodiment, the toolset 302 is a medical image processing tool set described by Zankowski inthe above referenced pending patent application. The medical imageprocessing tool set 302 receives a downloaded case study 106 thatcomprises a reference image set 202. As illustrated in FIG. 3, after themedical image processing tool set processes the current medical imageset 206 to produce the sparse landmark signature set 304, the referenceimage set 202 is registered to the medical image set 206 to create aregistered medical image set 306. Such a registered medical image set306 is therefore ready for consumer clinician review and editing as wellas uploading back to the knowledge exchange 102 for further review andfeedback from the clinical community as well as by the clinician whocontributed the selected case study 106. After the uploaded registeredmedical image set 306 and other associated electronic contents (e.g.,dose, radiotherapy treatment plan, etc.) making up the current medicalcase are downloaded and reviewed by the contributing clinician and anyothers selected by the consumer clinician, any provided feedback andediting of proposed contouring or treatment plans (for example) arereviewed by the consumer clinician, who after incorporating any desiredchanges creates a final medical case 308. The final medical case 308comprises the final medical image set 306 as well as associatedelectronic contents mentioned above.

In addition to rule sets for applying the reference image set to themedical image set, as described above, a case study also includes acontoured and segmented reference image set as an example forcomparison. This example contouring and segmenting provides a referenceset to compare with what the consumer clinician has come up with.

When a consumer clinician has downloaded a case study and applied it totheir patient, they have the ability to use the knowledge exchange tocommunicate directly with the contributing clinician, as well as anyoneelse they wish to communicate with. This will allow the consumerclinician to seek outside opinions, advice, and comment. Thecontributing clinician (and anyone else the consumer clinician hasallowed) will be given access to the consumer clinician's appliedtreatment plan through the knowledge exchange, where they can downloadthe applied case (deformed image set, contours, treatment plan, etc.)and view/edit it in their own tool set, including the ability to providefeedback comprising comments and suggestions as well as actual editingto the uploaded applied case, which will be sent back to the consumerclinician.

In an additional embodiment of the knowledge exchange, consumerclinicians, when they submit an applied case to the knowledge exchangefor review by the associated contributing clinician, will also be ableto request that other reviewing clinicians with acknowledged expertisein particular areas improve upon their applied case in those particularareas. Each reviewing clinician would review that portion of the appliedcase where they have expertise. The final result, with feedback, willprovide what the peer acknowledged “experts” in each particular fieldscan do in each area of the applied case, providing the best treatmentplan for the consumer clinician's patient. Therefore, after thisfeedback into a derivative case, based upon an expert case study, theconsumer clinician would be able to upload their own “expert case.” Itwould provide an additional example of what might be a rare case.

In one embodiment, consumer clinicians will be able to upload theirapplied case to the knowledge exchange and place it into a publicnetwork that other members of the knowledge exchange community will beable to see and access. For instance, an expert in head cases couldvolunteer to review all submitted brain cases (improving the contouringof these brain cases that have been submitted for review and feedback).In other words, a reviewing clinician may set it up so that theknowledge exchange notifies them whenever a particular kind of case getsposted to a public network for review within the knowledge exchange. Itis anticipated that when potential reviewers see that a consumerclinician has posted an applied case to a public network, they will beable to ask the consumer clinician if they would like them to review thecase. Such communication may take place through email, instant message,blogs, or chat rooms, for example.

Such participation of clinician reviewers allows the knowledge exchangecommunity to help further define what are best practices and to insurethat consumer clinicians who are downloading case studies and seekingreview and feedback have access to what is considered the current bestpractice. Such community cooperation will also ensure that protocoldevelopment for current technology continues, allowing the review of theactual use of the technology (e.g., currently used tool set).

FIG. 4 illustrates a flow diagram for a consumer using the knowledgeexchange. In step 402 a medical case is loaded into a tool set 302. Inone embodiment, after loading the medical case into the tool set 302, amedical image set 206 is reduced to a sparse landmark signature set 304.In step 404 the knowledge exchange is searched for case studies 106a-106 n with similar sparse signatures and meta-data. In step 406, theselected case study 106 is downloaded and loaded into the tool set. Instep 408, a reference image set 202 of the selected case study 106 isregistered to the medical image set 206 of the medical case. Inregistering the reference image set 202 to the medical image set 206,the contours and segmented structures of interest of the reference imageset are also registered to the medical image, such that the points ofthe sparse signature set of the reference image set 202 match the sparsesignature set of the medical image set 206. In step 410, the registeredmedical case, which includes the registered medical image set 306, isuploaded to the knowledge exchange. In step 412, a selected reviewerdownloads and reviews the registered medical case. In reviewing theregistered medical case, the contours and segmentation for the medicalimage set are also reviewed, along with the proposed radiotherapytreatment plan and other associated treatment steps. The selectedreviewer may be the contributor of the selected case study or anotherclinician who provides a review and feedback to the consumer clinician.In step 414, the reviewed medical case is returned to the consumerclinician (through the knowledge exchange) and loaded into the tool set302 for review. In step 416, the downloaded reviewed medical case isreviewed by the consumer clinician and any necessary changes are made tocreate a final medical case. In one embodiment, the consumer reviews thereviewed medical case which contains an edited registered medical case,and after any other changes, saves the reviewed medical case as a finalmedical case. In another embodiment, the consumer reviews the reviewedmedical case which contains an edited registered medical case andincorporates any desired changes from the reviewed medical case into theregistered medical case to create a final medical case.

FIG. 5A illustrates steps to a procedure for uploading and peerreviewing a case study submitted by a contributing clinician. In step502, a contributing clinician uploads a case study into the database ofthe knowledge exchange. The uploaded case study will contain electronicrecords comprising: a reference image set, radiation therapyprescriptions, delineation of organs, tumors and regions within thereference image set for treatment planning (contours and segmentation oforgans and/or structures of interest), radiation therapy treatmentplanning, and radiation therapy treatment protocols and processdescriptions, etc. In step 504, the uploaded case study is downloadedand peer reviewed. In peer reviewing, each reviewer who downloaded thesubmitted case study assigns a rating (e.g., selecting a numericalrating of 1-5) and optionally drafts a written review of the submittedcase study. In one embodiment, the submitted case study will also bereviewed by a clinical advisory board that previews all case studiesbefore allowing them to be published. However, any member of theknowledge exchange community (consumers, providers, and otherclinicians) will be able to download and review submitted case studiesto help contribute to a peer rating for the submitted case study. Inanother embodiment, the clinical advisory board will be maintained torecognize and certify popular and highly rated contributions.

FIG. 5B illustrates steps to a procedure for receiving reviews andfeedback after downloading and applying components of a case study to acurrent medical case. In step 506, the consumer clinician selects whothey wish to review a registered medical case that is ready for review.In one embodiment, the consumer clinician selects a single reviewer,such as the contributing clinician who authored the selected case study.In another embodiment, the consumer clinician may select a differentreviewer to review the registered medical case. In step 508 the selectedreviewer downloads the registered medical case. In one embodiment, anindividual reviewer may be able to download the entire medical caseuploaded for review, or only a portion of it. In other words, there maybe only portions of the medical case that have been submitted forreview. In step 510, the selected or permitted reviewer reviews thedownloaded medical case. In reviewing the submitted medical case, areviewer may merely provide written feedback or in addition may edit thecontents of the medical case submitted for review (e.g., adjusting theposition of the contours in the medical image set and adjusting theradiation therapy prescription, etc.). After completing the review, thefeedback is sent to the consumer clinician (through the knowledgeexchange). Such feedback may be as simple as a text document or thesubmitted medical case with editing such that it is now considered areviewed medical case. In step 512, the consumer clinician receives thefeedback from a reviewer. When the feedback is in the form of a reviewedmedical case, it is loaded into the tool set for further review by theconsumer clinician. In step 514, the user reviews the downloadedfeedback and/or reviewed medical case, edits the registered medical casebased on the feedback and creates a final medical case that may be usedto treat the patient.

FIG. 5C illustrates steps for a further implementation of a method forenabling multiple reviewers to submit reviewed medical cases to theconsumer clinician. In step 516, the consumer clinician selects whichreviewers they desire to review the medical case. The medical case isalso uploaded to the knowledge exchange. The submitted medical casecomprises radiation therapy prescriptions, delineation of organs, tumorsand regions within the medical image set for treatment planning(contours and segmentation of organs and/or structures of interest),radiation therapy treatment planning, and radiation therapy treatmentprotocols and process descriptions, for example that are based upon thedownloaded case study that was applied to the medical case with the toolset. In step 518, each reviewer of a plurality of reviewers aredownloading and reviewing the submitted medical case. When reviewing,each reviewer will separately review the submitted medical case andprovide separate feedback to the consumer clinician (through theknowledge exchange). In reviewing the submitted medical case, a reviewermay merely provide written feedback or in addition may edit the contentsof the medical case submitted for review (e.g., adjusting the positionof the contours in the medical image set or adjusting the radiationtherapy prescription, etc.). After completing the review, the feedbackis sent to the consumer clinician (through the knowledge exchange). Suchfeedback may be as simple as a text document or the submitted medicalcase with editing such that it is now considered a reviewed medicalcase. In step 520, the consumer clinician receives feedback from theplurality of reviewers. The consumer clinician downloads and reviews thefeedback provided and incorporates those portions of the feedback thatthey approve of into the medical case to create a final medical case.When a plurality of reviewers have provided feedback, each feedback willbe reviewed separately and incorporated into the submitted medical caseto create a final medical case. In other words, the consumer clinicianmay be required to consolidate feedback from multiple reviewers into asingle suggested change for the submitted medical case or a plurality ofchanges. It may also be necessary for the consumer clinician to send outan updated medical case for further review by the same reviewers, aportion of the original reviewers, or selected different reviewers. Thismay especially be the case when several of the reviewers have suggestedcontradictory corrections to the medical case.

Capabilities of the Knowledge Exchange During Implementation

An implementation embodiment of the knowledge exchange comprisesimplementations involving web-enabled clinical collaboration, IPinfrastructure, Tool Set modifications, and a phased implementationplan.

A web-based infrastructure will be created to support knowledge exchangecapabilities to allow the implementation of an online collaborativecommunity. Such an online collaborative community will facilitate theexchange of best practice discussions between clinicians. Thiscommunication between clinicians will not be altered. The web-basedinfrastructure in this embodiment does not include an exchange of thirdparty applications. Third party applications exchange would be added tothe Knowledge Exchange at a later phase.

An embodiment of the knowledge exchange will include a tool set with theability to create, edit and save case studies to the knowledge exchange;add clinical content for the case including recommended prescriptions,treatment plans, and care paths; the ability to export cases and postthem on the knowledge exchange website; download cases from theknowledge exchange and import them into the tool set; and an additionalsearch parameter that recognizes different clinical tool sets andprocess.

In an exemplary embodiment, the knowledge exchange will undergo a phasedimplementation plan. Phase I will comprise the establishment of acollaborative website. The website will be available for posting anddiscussion of radiotherapy clinic topics. In the initial release it willnot include the electronic clinical content files. This website will befor clinicians to post cases and provide each other advice on the cases.All required web infrastructure will be in place.

Phase II will comprise a proof of concept on digital clinical content.In parallel with the establishment of the collaborative website, workwill begin on a proof of concept for digital clinical content. Two orthree clinical sites will be selected. The ability to extract and reloadclinical content by disease site, stage, and technology base, will beproven.

Phase III will comprise a pilot of a digital clinical content exchange.Upon completion of the proof of concept a pilot program will be launchedfocused on a specific disease site and technology and a selected groupof customers. The pilot will be used to further refine the collaborativewebsite and exchange implementation framework. In an exemplary pilotprogram, 5-10 participants may be initially targeted as knowledgecontributors and 25-50 sites will be identified as knowledge consumers.

Phase IV will comprise the launch of a digital clinic content exchangeon the website. This will merge the collaborative website and theability to upload and download electronic clinical content together.Future phases will include the ability to link data sets and outcomesanalysis, and the ability to upload and download third partyapplications which run on the product platform (tool set). In additionalembodiments, available tool sets provided by third party companies maybe marketed and sold as entities separate from the fundamental knowledgeexchange. In further embodiments, an online tool set may be providedwhich is accessible through a further embodiment of the knowledgeexchange and can be purchased for use on an as needed basis.

As discussed above, as technology and available methods improve, the gapbetween actual and best practice continues to widen. A mix shift fromdeveloped to emerging markets exacerbates the problem as the rapidgrowth in emerging markets means a shortage of trained personnel andinfrastructure to support advance technology. Therefore, the followingembodiments of the knowledge exchange provide the following benefits.

An embodiment of the knowledge exchange implementing only thecollaborative website will allow clinicians to give each other adviceand discuss clinically relevant topics, and will contribute to thesharing of best practices thereby improving the use of tool setsassociated with embodiments of the knowledge exchange.

A recommended embodiment of the knowledge exchange will implement thecollaborative website, enable the importing and exporting of clinicalcontent from associated tool sets at a given website, and enableclinical content sharing on the collaborative website. Such animplementation will allow clinicians to share actual electronic casestudies to increase direct sharing of best practices for a giventechnology platform or tool set, providing a platform enablingcommunication of best practices, allowing knowledge creators/authors andconsumers to extract the maximum value from their investment in theknowledge exchange, and provide improved clinical safety by providingmore clinical support tools.

A best solution embodiment of the knowledge exchange implements: thecollaborative website; enabling the importing and exporting of clinicalcontent from associated tool sets at a given website; clinical contentsharing on the collaborative website; automatic aggregation of clinicaldata into a data warehouse for outcomes analysis such that clinicalcontent can be substantiated with outcomes data; and allowing thesharing of third party applications that connect through animplementation's API. Such an implementation will link clinicaldecisions and processes in radiation oncology and medical oncology topatient outcomes. It will increase the development of advancedtechnology by further engaging partners to develop solutions onplatforms (tool sets) associated with the present invention. And takesthe collaborative strategy to the next step by linking the processdefinitions to outcomes and establishing a developer community.

Beneficiaries of the Knowledge Exchange

Patient: patients have a higher likelihood of being treated with themost effective and safest treatment available to the clinic in whichthey are treated. Patients may (if outcomes are reached) be able toreview prognosis with their oncologist, and help select their owntreatment based on reliable statistics.

Physicist: Peer recognition and networking, ability to share newtechniques with the community; opportunity to make money by postinguseful applications; greater productivity; and access to best practicein quality assurance for specific techniques.

Dosimetrist: Access to benchmarks for what is achievable for a giventype of case; greater productivity; and peer recognition and networking.

Physician: Opportunity to share and discuss challenging cases withpeers; tools to capture own best practice internally for their own usein later cases; examples of best practices in the form of expertclinical cases from others; and improved productivity (contouring, doseprescriptions) derived from the use of clinical cases.

Hospital Administrators: Content for administrators may consist ofimproved reports, dashboards, and enhanced marketability based on provenbest practice and/or clinician ratings from the Knowledge Exchangecommunity.

Implementers: Opportunity to hear firsthand what customers are saying toother customers about their products and the competitors; ability toreceive direct customer feedback about implemented products; access tothird party applications for eventual incorporation into the coreplatform; ability to listen in on peer to peer discussions regardingimplemented products and tool sets, the website will provide an ongoingopportunity to learn how the implemented products are used, where theyare effective, where they are deficient, and to see examples of how toimprove product relevance; and the opportunity to learn more about howimplemented products are used by customers.

Benefits of the Knowledge Exchange

The Knowledge Exchange will create a new, collaborative environment forclinicians. This new venue will increase the ability of clinicians toshare best practices with each other, thereby increasing the safe andeffective use of technology in treating cancer. Significantopportunities are available in developing product platforms forcollaboration and engagement of customers and partners. Bringing theseproven tools into Oncology will give the implementer the mostcomprehensive solution incorporating both products and services, withcollaboration on clinical best practices.

As available tools sets for cancer treatments are advanced, moretechnology means more clinical choices and complexity. The key questionis who will make the clinical choices to apply this technology andprovide the “push button” simplicity necessary for safe, widespreadadoption. Rather than the implementer of the knowledge exchange makingthese choices and “baking” them into the product, the digital clinicalcontent concept enables clinicians to make these choices and offer themto other clinicians. The role of the implementer of the knowledgeexchange then becomes one of enabling and sharing the clinical choicesmade by clinical experts.

The knowledge exchange can also be used as a repository for clinicalresearch studies. Clinical studies in the knowledge exchange can be madeavailable to practitioners who wish to participate in the study. Suchclinical studies can focus on a particular treatment protocol. Aprotocol can be as simple as text documents describing a proposedtreatment plan with specific treatment limitations (e.g., a particulartumor to receive a specific dosage, with surrounding organs receiving nomore than a further specified dose level); to a more detailed treatmentplan that approaches the complexity of an expert case. In oneembodiment, the protocol itself can be tied with a particular expertcase to aid in repeatability, such that the treatment described in theprotocol of the clinical study will be carried out in conjunction withthe use of the expert case. In further embodiments, the knowledgeexchange can also be a repository for results of particular clinicalresearch studies.

In an exemplary embodiment, an institution, such as one that contributescase studies as described above, may conduct a clinical study bycreating an expert case as a form of protocol and solicit participantsfor a research study of this protocol. A private online community may becreated for this purpose utilizing the knowledge exchange. Participatingclinicians in the clinical study will download and use the aboveprotocol (e.g., expert case) in their respective tool sets and then posttheir feedback and outcome data back to this private online communityfor review. Such efforts may be used to create a clinical study paper.This clinical study paper could then be submitted to peer reviewedjournals and “published” in both traditional peer reviewed journals andin the public domain of the knowledge exchange with both itemscross-referencing each other. Or the paper could be only “published”online through the knowledge exchange. The contributing institute willbenefit in having focused research participants providing outcomes data,and the knowledge consumer institutions will benefit in participating inthe clinic study by accessing advanced techniques and feedback on theiruse. Finally, the results of the research study as embodied in an expertcase can be used by consumer clinicians as a basis for applying atreatment or planning protocol to a patient, with the clinical consumerand patient benefiting from the results of the research study.

Further, as best practices improve, clinicians will be able to connectan outcome with a protocol. The desire is so be able to connect alloutcomes that followed particular protocols to show the results whenparticular protocols were followed. Therefore the knowledge exchangewill aid in linking protocols to outcomes to enable further outcomeanalysis for particular types of cases. In further developments, progenyof source protocols will also be linked to allow further analysis ofprotocols as they relate to outcomes.

Further Uses of the Knowledge Exchange

The Knowledge Exchange provides tools for the private capturing, sharingand reuse of proprietary clinical knowledge within a clinical setting.Some clinical locations will wish to extend this expertise to others aspart of a business plan and branding strategy. The Knowledge Exchangeenhances this business strategy by offering a delivery means to helpensure quality and comprehensiveness.

The Knowledge Exchange provides a method to deploy nationwide standardsof care. The standards of care together with equipment and software maybe deployed as part of a nationwide cancer initiative. The KnowledgeExchange helps achieve these clinical standards across geographicallydispersed primary and secondary cancer centers.

Smaller and more remote clinical locations can use the KnowledgeExchange to collaborate with other clinics on difficult cases, inclinical adoption of new technology, and to share outcomes and bestpractices.

In parallel with improved platform technologies, academic and innovativecenters can introduce clinical use cases which leverage the newtechnology clinically. In a manner similar to publishing papers, theKnowledge Exchange offers these centers a tangible way to gainreputation and prestige as leaders in the field of Radiation Therapy.

Summarizing the Knowledge Exchange

In summary, the knowledge exchange will provide an electronic filecontaining a complete clinical template for an expert case includingcontours, treatment plans, and treatment protocols. The knowledgeexchange will combine the electronic files, discussion forums, andrelated clinical information into an internet site that is searchable bytype of disease, stage and clinical tool set, as well as otherparameters discussed above. The knowledge exchange will allow a user(e.g., a clinician) to create and save their own clinical case for reuseand sharing with others. In the knowledge exchange, the clinical case isthe intellectual property (IP) of the clinician posting the case. Theposter can set the IP status and whether or not there will be a chargeto download the case when posting. Lastly, other participants using theknowledge exchange will be able to rate a particular case study for itsusefulness and assigning it a rating that will be linked to the case andthe poster. These ratings can then be used to determine whether or not aposted case study will be considered an “expert case.”

Although certain preferred embodiments and methods have been disclosedherein, it will be apparent from the foregoing disclosure to thoseskilled in the art that variations and modifications of such embodimentsand methods may be made without departing from the spirit and scope ofthe invention. It is intended that the invention shall be limited onlyto the extent required by the appended claims and the rules andprinciples of applicable law.

What is claimed is:
 1. A method, comprising: receiving, via a web sitefor a knowledge exchange system, from a first clinician at a firstlocation, a current medical case that is stored as an electronic fileand comprises a first treatment plan for a first patient; searching adatabase in the knowledge exchange system, the database comprising aplurality of case studies uploaded by clinicians to the knowledgeexchange system, each of the case studies in the plurality of casestudies stored as one or more electronic files that comprise metadataand a respective treatment plan, said searching comprising a searchengine at the web site searching the metadata; selecting a case studyout of the plurality of case studies, wherein the case study is selectedbased upon at least one similarity between the selected case study andthe current medical case, wherein the selected case study is for asecond patient different from the first patient and wherein the selectedcase study comprises reference images comprising two-dimensional slicesand a plurality of segments and contours corresponding to structures ofinterest in the slices and also comprises a second treatment plan andfirst outcome information describing the outcome of treating the secondpatient according to the second treatment plan; downloading at least aportion of the selected case study from the knowledge exchange system,wherein the downloaded portion of the selected case study is downloadedinto a tool set that also accesses the current medical case and whereinthe downloaded portion comprises the reference images, wherein the toolset imports and exports electronic content of case studies from and toanother, different tool set via the knowledge exchange system, whereinthe knowledge exchange system implements an application programminginterface (API) that enables importing and exporting of the electroniccontent from and to the different tool set; applying the downloadedportion of the selected case study to the current medical case, whereinsaid applying comprises using deformable registration of at leastportions of the reference images of the downloaded portion of theselected case study to conform to at least portions of medical images ofthe current medical case to create a registered medical image set, andwherein the medical images of the current medical case and the referenceimages of the downloaded portion of the selected case study are for thefirst and second patients, respectively; uploading the current medicalcase including the registered medical image set and the first treatmentplan to the knowledge exchange system after application of thedownloaded portion of the selected case study, wherein said uploadingthe current medical case notifies reviewers that the current medicalcase is available for review; receiving, via the web site, a pluralityof feedbacks from the reviewers on the current medical case; providingthe feedbacks to the first clinician via the web site; receiving, viathe web site, a final medical case based on the current medical case andthe feedbacks, the final medical case including a final version of thefirst treatment plan; uploading the final medical case to the knowledgeexchange system and adding the final medical case to the plurality ofcase studies stored in the database; accessing second outcomeinformation describing the outcome of treating the first patientaccording to the final version of the first treatment plan; determininga statistical link between the second treatment plan and the finalversion of the first treatment plan and the respective outcomes of thesecond treatment plan and the final version of the first treatment plan;and uploading the statistical link to the knowledge exchange system. 2.The method of claim 1, wherein the downloaded portion of the selectedcase study is selected from the group consisting of: the meta data, animage set, a document-based file, an image-based file, an executable, acontour, and a treatment protocol.
 3. The method of claim 1, wherein themetadata is selected from the group consisting of: weight, height, sex,age, race, size of patient, diagnosis, treatment site, whether or notthere is nodal involvement, any co-morbidities, side of the body, andapproximate location of tumor, stage, and desired treatment techniques.4. The method of claim 1, wherein the tool set is capable of performingthe deformable registration.
 5. The method of claim 1, furthercomprising making an electronic payment to the clinicians.
 6. The methodof claim 1, further comprising uploading the final medical case to theknowledge exchange system as a new case study, wherein the new casestudy is stored with the plurality of case studies.
 7. The method ofclaim 1, wherein each case study of the plurality of case studies isassociated with a respective peer review score and each cliniciancontributing a case study is associated with a respective reputationscore.
 8. The method of claim 7, wherein searching the plurality of casestudies further comprises searching by at least one of minimum casestudy peer review score and minimum poster reputation score.
 9. Themethod of claim 1, wherein at least one case study of the plurality ofcase studies is part of a clinical study.
 10. A non-transitory computerreadable media comprising computer-executable instructions storedtherein, the computer-executable instructions comprising: instructionsto search a plurality of cases studies provided by clinicians anduploaded to a knowledge exchange system in a network, each of the casestudies in the plurality of case studies stored in a database as one ormore electronic files that comprise metadata allowing the files to besearched by a search engine and that also comprise a respectivetreatment plan; instructions to select a case study out of the pluralityof case studies, wherein the case study is selected based upon at leastone similarity between the selected case study and a current medicalcase that is received from a first clinician at a first location,wherein the current medical case is for a first patient and comprises afirst treatment plan and wherein the selected case study is for a secondpatient different from the first patient and comprises a secondtreatment plan and first outcome information describing the outcome oftreating the second patient according to the second treatment plan, andwherein the selected case study further comprises reference imagescomprising two-dimensional slices and a plurality of segments andcontours corresponding to structures of interest in the slices;instructions to download at least a portion of the selected case studyfrom the knowledge exchange, wherein the case study is downloaded into atool set that also accesses the current medical case and wherein thedownloaded portion comprises the reference images, wherein the tool setimports and exports electronic content of case studies from and toanother, different tool set via the knowledge exchange system, whereinthe knowledge exchange system implements an application programminginterface (API) that enables importing and exporting of the electroniccontent from and to and to the different tool set; instructions to applythe downloaded portion of the selected case study to the current medicalcase, wherein the downloaded portion of the selected case study isapplied using deformable registration of at least portions of thereference images of the downloaded portion of the selected case toconform to at least portions of medical images of the current medicalcase to create a registered medical image set, and wherein the medicalimages of the current medical case and the reference images of thedownloaded portion of the selected case study are for the first andsecond patients, respectively; instructions to upload the currentmedical case including the registered medical image set and the firsttreatment plan to the knowledge exchange system after application of thedownloaded portion of the selected case study, wherein uploading thecurrent medical case comprises allowing clinicians at differentlocations to download and review at least a portion of the currentmedical case; instructions to receive a plurality of reviewed medicalcases comprising feedbacks on the current medical case includingcomments and edits from the clinicians at the different locationsproduced via an online collaborative exchange of information between theclinicians; instructions to apply the reviewed medical cases to thecurrent medical case to create a revised medical case; instructions toprovide the feedbacks to the first clinician; instructions to upload tothe knowledge exchange system a final medical case based on the revisedmedical case and the feedbacks, the final medical case including a finalversion of the first treatment plan; instructions to add the finalmedical case to the plurality of case studies stored in the database;instructions to access second outcome information describing the outcomeof treating the first patient according to the final version of thefirst treatment plan; instructions to determine a statistical linkbetween the second treatment plan and the final version of the firsttreatment plan and the respective outcomes of the second treatment planand the final version of the first treatment plan; and instructions toupload the statistical link to the knowledge exchange system.
 11. Thenon-transitory computer readable media of claim 10, wherein thedownloaded portion of the selected case study is selected from the groupconsisting of: the meta data, an image set, a document-based file, animage-based file, an executable, a contour, and a treatment protocol.12. The non-transitory computer readable media of claim 10, whereinuploading the current medical case after application of the downloadedportion of the selected case study notifies reviewers that the currentmedical case is available for review.
 13. The non-transitory computerreadable media of claim 10, wherein the metadata is selected from thegroup consisting of: weight, height, sex, age, race, size of patient,diagnosis, treatment site, whether or not there is nodal involvement,any co-morbidities, side of the body, and approximate location of tumor,stage, and desired treatment techniques.
 14. The non-transitory computerreadable media of claim 10, wherein the tool set is capable ofperforming the deformable registration.
 15. The non-transitory computerreadable media of claim 10, further comprising instructions to make anelectronic payment to the first clinician.
 16. The non-transitorycomputer readable media of claim 13, wherein the searching of theplurality of case studies is performed with a search engine on a websitefor the knowledge exchange system.
 17. The non-transitory computerreadable media of claim 10, further comprising instructions to uploadthe final medical case to the knowledge exchange system as a new casestudy, wherein the new case study is stored with the plurality of casestudies.
 18. The non-transitory computer readable media of claim 10,wherein each case study in the plurality of case studies is associatedwith a respective a peer review score and each clinician contributing acase study is associated with a respective reputation score.
 19. Thenon-transitory computer readable media of claim 18, wherein searching aplurality of case studies further comprises instructions to search by atleast one of minimum case study peer review score and minimum posterreputation score.
 20. The non-transitory computer readable media ofclaim 10, wherein at least one case study of the plurality of casestudies is part of a clinical study.
 21. The method of claim 1, whereinthe final medical case is rated by the clinicians and classified as anexpert case if its rating is high enough, and wherein if classified asan expert case then the final medical case is useable as a treatmentprotocol.
 22. A method, comprising: searching a database comprising aplurality of case studies in a knowledge exchange system on a network,each of the case studies comprising metadata and a respective treatmentplan; selecting a case study out of the plurality of case studies,wherein the case study is selected based upon at least one similaritybetween the selected case study and a current medical case comprising afirst treatment plan, and wherein the selected case study is provided bya clinician and stored in the database and comprises a second treatmentplan and first outcome information describing the outcome of treating apatient according to the second treatment plan, the selected case studyfurther comprising reference images comprising two-dimensional slicesand a plurality of segments and contours corresponding to structures ofinterest in the slices; downloading at least a portion of the selectedcase study from the knowledge exchange system via the network, whereinthe downloaded portion of the selected case study is downloaded into atool set that also accesses the current medical case and wherein thedownloaded portion comprises the reference images, wherein the tool setimports and exports electronic content of case studies from and toanother, different tool set via the knowledge exchange system, whereinthe knowledge exchange system implements an application programminginterface (API) that enables importing and exporting of the electroniccontent from and to the different tool set; applying the downloadedportion of the selected case study to the current medical case, whereinsaid applying comprises deformable registration of at least portions ofthe reference images of the downloaded portion of the selected casestudy to conform to at least portions of medical images of the currentmedical case to create an applied case study; uploading one or morepieces of a case study created by a contributing clinician to thedatabase of the knowledge exchange system; downloading the case studyfrom the contributing clinician to different reviewers at differentlocations; uploading the current medical case including the registeredmedical image set and the first treatment plan to the knowledge exchangesystem after application of the downloaded portion of the selected casestudy, wherein said uploading the current medical case notifies thedifferent reviewers that the current medical case is available forreview; conducting, via a web site, an online collaborative exchange ofinformation between the different reviewers; receiving, via the website, feedbacks on the current medical case from the differentreviewers, to create a plurality of reviewed medical cases; applying thereviewed medical cases to the case study from the contributing clinicianto create a revised medical case; providing the revised medical case tothe contributing clinician via the web site; receiving, via the website, a final medical case based on the current medical case and thefeedbacks, the final medical case including a final version of the firsttreatment plan; uploading the final medical case to the knowledgeexchange system and adding the final medical case to the database;accessing second outcome information describing the outcome of treatingthe first patient according to the final version of the first treatmentplan; determining a statistical link between the second treatment planand the final version of the first treatment plan and the respectiveoutcomes of the second treatment plan and the final version of the firsttreatment plan; and uploading the statistical link to the knowledgeexchange system.
 23. The method of claim 22, wherein the one or morepieces of the case study uploaded to the knowledge exchange system areselected from the group consisting of: treatment plan parameters; themedical images of the current medical case; a registered medical imageset resulting from the deformable registration of the reference imagesto conform to the medical images of the current medical case; contouringand segmentation of organs of interest included in the registeredmedical image set; a follow-on care path for a patient represented inthe applied case study; and an outcome for a patient represented in theapplied case study.
 24. The method of claim 22, wherein the currentmedical case is for a first patient and the selected case study is for asecond patient different from the first patient, and wherein the medicalimages of the current medical case and the reference images of thedownloaded portion of the selected case study are for the first andsecond patients, respectively.
 25. A method, comprising: receiving, viaa web site for a knowledge exchange system on a network, from a firstclinician at a first location, a current medical case that is stored asan electronic file in a database in the knowledge exchange system andthat comprises a first treatment plan for a first patient; searching aplurality of case studies, each of the case studies in the plurality ofcase studies provided by clinicians and stored in the database as one ormore electronic files that comprise metadata and a respective treatmentplan, said searching comprising a search engine at the web sitesearching the metadata; selecting a case study out of the plurality ofcase studies, wherein the case study is selected based upon at least onesimilarity between the selected case study and a current medical case,wherein the selected case study is for a second patient different fromthe first patient and wherein the selected case study comprisesreference images comprising two-dimensional slices and a plurality ofsegments and contours corresponding to structures of interest in theslices and also comprises a second treatment plan and first outcomeinformation describing the outcome of treating the second patientaccording to the second treatment plan; downloading at least a portionof the selected case study from knowledge exchange system over thenetwork to a tool set, wherein the downloaded portion comprises thereference images, wherein the tool set imports and exports electroniccontent of case studies from and to another, different tool set via theknowledge exchange system, wherein the knowledge exchange systemimplements an application programming interface (API) that enablesimporting and exporting of the electronic content from and to thedifferent tool set; applying the downloaded, selected case study to thecurrent medical case, wherein the downloaded, selected case study isapplied using deformable registration of at least portions of thereference images of the downloaded, selected case study to conform to atleast portions of medical images of the current medical case, whereinthe medical images of the current medical case and the reference imagesof the downloaded portion of the selected case study are for the firstand second patients, respectively; uploading the current medical caseincluding the medical images to the knowledge exchange system afterapplication of the downloaded portion of the selected case study,wherein said uploading the current medical case notifies reviewers thatthe current medical case is available for review; receiving, via the website, feedback from the reviewers on the current medical case;providing, to the first clinician via the web site, a revised medicalcase incorporating the feedback into the current medical case;receiving, via the web site, a final medical case based on the currentmedical case and the feedback and including a final version of the firsttreatment plan; uploading the final medical case to the knowledgeexchange system and adding the final medical case to the plurality ofcase studies in the database; accessing second outcome informationdescribing the outcome of treating the first patient according to thefinal version of the first treatment plan; and determining a statisticallink between the second treatment plan and the final version of thefirst treatment plan and the respective outcomes of the second treatmentplan and the final version of the first treatment plan; and uploadingthe statistical link to the knowledge exchange system.
 26. The method ofclaim 1, wherein the medical images of the current medical case arereduced to sparse landmark signatures, wherein the reference images ofthe selected case study have sparse landmark signatures thatsatisfactorily match the sparse landmark signatures of the currentmedical case.